The demand for cancer and other chronic disease health-care services is increasing mainly because of the growing and aging population. With advances in cancer screening and treatment, more people are living with a diagnosis of cancer for longer periods of time. While this is a good thing, it can be challenging for the health-care system. It can also be challenging for cancer survivors themselves because there can be significant effects that come later in treatment and/or that remain after treatment is done. The quality of cancer and chronic disease care needs to be maximized while at the same time making sure that the provincially based health-care system is sustainable in the long term.
Created in collaboration with The College of Family Physicians of Canada and the Canadian Association of Provincial Cancer Agencies, the goal of the Primary Care and Cancer Care Integration Initiative is to investigate best practices that improve transitions of care between cancer specialists and primary care settings. The hope is to ultimately have a better patient experience, enhanced quality of care and greater efficiency in the primary care and cancer care systems.
The following projects, that are all part of this initiative, focus on the time after a diagnosis has been confirmed and primary cancer treatment has been provided.
Project overview and goals
This project aims to improve the First Nations, Inuit and Métis cancer patient transition experience and increase knowledge and information about the specific care needs of this population.
This project emphasizes trust and relationship-building between First Nations, Inuit and Métis people living with cancer and their primary and oncology care providers as well as other stakeholders. The goal is to generate a mutual understanding of needs and perspectives.
The Government of the Northwest Territories Department of Health and Social Services (GNWT–DHSS), is the lead for this project. The project was implemented in the following three phases from January 2014–January 2017.
- Phase one built on the work of the Canadian Partnership Against Cancer First Nations, Inuit and Métis Action Plan on Cancer Control through relationship-building and finalizing ethics protocols for culturally safe work.
- Phase two explored the experiences of First Nations, Inuit and Métis patients as they transitioned from community to primary care to oncology care and then transitioned back from oncology care to primary care to community care.
- Phase three focussed on spreading transition support resources among primary care networks/providers and First Nations, Inuit and Métis communities in the Northwest Territories, British Columbia, Alberta, and Manitoba.
- Government of the Northwest Territories Department of Health and Social Services (GNWT–DHSS), Northwest Territories
- Alberta Health Services (AHS), Alberta
- Cancer Care Manitoba, Manitoba
- The Northern British Columbia Cancer Agency, British Columbia
- Saint Elizabeth Health Care, Ontario
- First Nations, Inuit, and Métis communities in the Northwest Territories, British Columbia, Alberta, and Manitoba
Project overview and goals
With advances in cancer prevention, early detection and treatment, the number of cancer survivors in Canada is growing. Survivors have expressed that they need support to be the healthiest they can be after completing their cancer treatment.
The goal of this project is to leverage existing resources to more effectively support breast and colorectal cancer patients as they transition from active cancer care to primary care. We also seek to better equip primary care providers to support patients in transition.
The project will be implemented using the following sub-components:
- evaluating information needs for treatment summaries with breast cancer patients,
- developing volunteer transition navigator roles in BC and Nova Scotia to provide peer support and information about existing resources,
- creating a web-based survivorship portal where patients can set and monitor personal goals for their “new normal”,
- evaluating the use of cancer follow-up guidelines in primary care.
Together, these initiatives and resources will support breast and colorectal cancer survivors to get informed about, and take an active role in, their survivorship care as well as engage in healthy lifestyle activities.
- BC Cancer Agency (Survivorship and Primary Care, BC Cancer Research Centre, and Family Practice Oncology Network)
- Canadian Cancer Society (BC and Yukon Division)
- Canadian Cancer Society (Nova Scotia Division)
- Cancer Care Nova Scotia
- BC Alliance on Telehealth Policy and Research
- BC Ministry of Health Services’ Patient Reported Experience Measures (BC PREMS) Steering Committee
This project will use an innovative approach to enhance provider integration for cancer survivors.
Building on work from Ontario, Manitoba and British Columbia, the team will:
- develop a collaborative residency training curriculum that supports early training education and strengthens relationships between primary care residents and oncology residents though a structured training program,
- conduct research in different regions to find re-entry support structures and processes available in different regional cancer programs and use this to figure out how to better support primary care providers,
- develop and test the use of an electronic platform for survivorship care plans to enhance exchange of knowledge between providers and maintain the continuity of care for patients during transition.
- Cancer Care Ontario (CCO), Ontario
- Cancer Care Manitoba (CCMB), Manitoba
- British Columbia Cancer Agency (BCCA), British Columbia